Three bills could bring broader medical practice

A trio of bills under consideration by the state Senate would allow nurse practitioners to see patients without supervision of doctors and would significantly expand the ability of optometrists and pharmacists to provide primary care to patients.

The bills are being promoted as a way to help increase treatment capacity at a time when federal health reform is poised to provide coverage to millions of currently uninsured Californians and some organizations have predicted a doctor shortage.

But detractors, including the California Medical Association, which represents more than 37,000 doctors, warn that the proposed changes could harm patients.

State Sen. Edward Hernandez, D-West Covina, who introduced all three bills, said they would help the state’s health care system absorb the millions of newly insured and not erode quality. He is backed by the statewide groups of nurse practitioners, pharmacists and optometrists.

“They will not be allowed to do more than what they are trained for,” said Hernandez, himself an optometrist.

Dr. Paul R. Phinney, president of the California Medical Society, countered that supporters of the changes are not being honest about their motives.

“I think they see a new opportunity to use the Affordable Care Act, and the workforce shortage in health care, as something that justifies what they’re trying to do,” Phinney said.

In 2009, the California HealthCare Foundation found that only 16 of 58 counties had enough primary care doctors when compared with American Medical Association standards.

While San Diego County was listed as one of the counties that had enough primary care doctors in 2009, that could change as health reform and an aging population increase the need for doctors more quickly than the supply.

Nurse practitioners

State law now allows registered nurses to become nurse practitioners by getting a master’s or doctorate-level degree in nursing or a related discipline and by completing an accredited nurse practitioner program. Doing so allows them to see patients, draw up plans of care, order tests and prescribe medication under the direct supervision of a licensed physician.

Nurse practitioners would also be able to certify a patient’s disability, order hospice care and delegate duties to a medical assistant.

Phinney said doctors are concerned the bill would put nurse practitioners in charge of diagnosis, a domain that doctors are better equipped to perform because they have thousands more hours of clinical residency training.

“The difference comes in the breadth of diagnoses that are considered and the efficiencies that doctors can come out with by picking the right treatments,” Phinney said.

He added that some studies have shown that nurse practitioners tend to order more tests than doctors and other diagnostic procedures that can increase the cost of health care.

Nurse practitioners come with their own studies.

Beth Haney, president of the California Association of Nurse Practitioners, noted that 18 states and the District of Columbia have passed independent practice bills. She said there is no evidence that independent practice leads to a rash of misdiagnosis.

She said the main reason that nurse practitioners are seeking independent practice is efficiency. For example, if a nurse orders a test for a patient, the results are delivered to the supervising doctor, even if he or she has never once seen the patient, she said.

Part of the process of moving from registered nurse to nurse practitioner is learning to understand when it is time to seek consultation from a medical doctor, she said.

“If there is a complex patient situation, we would obviously be referring to a physician. That’s our professional responsibility,” she said.

She argued that not requiring nurse practitioners to co-locate with doctors would also allow them to move to underserved parts of the state, such as rural or poor urban communities.

Optometrists

Today, optometrists can perform eye exams, prescribe prescriptions lenses, treat eye infections like conjunctivitis and diagnose and treat many other types of eye-related disease, like glaucoma, with special additional certifications from the state board of optometry. They are required to consult with an ophthalmologist in certain cases that would be reduced under the bill, SB492.

The bill would redefine the practice of optometry, and would allow practitioners to diagnose and treat “any disease, condition or disorder of the visual system, the human eye, and adjacent and related structures, even administering narcotic drugs and immunizations with the proper certification from the optometry board.”

The changes are not limited to the visual system. A separate section of the bill allows an optometrist to diagnose “other conditions that have ocular manifestations, initiate treatment, and, in consultation with a physician, manage medications for these conditions.

That sentence raises the hackles of the medical association.

Phinney, the CMA president, said the paragraph is so vague that it could be interpreted to mean that optometrists could treat cancer or HIV and a host of other serious conditions that can show up in the eye.

“The bill language is crazy, because it basically allows optometrists to treat any condition that manifests in the eye,” Phinney said. “That is so wide open that it’s dangerous and reckless.”

Hernandez, a licensed optometrist, said the language is not intended to allow treatment of cancer or any other specialized disease. Rather, the said that it is intended to allow broader latitude with chronic diseases like diabetes, which is often first detected by an optometrist in the course of a regular eye exam. He said optometrists already take basic medical histories of their patients, which include blood pressure, height, weight and sometimes even blood glucose.

“In collaboration with a physician, we should be able to start those medications, and get them into a primary care medical home,” Hernandez said.

Pharmacists

A third bill, SB493, would allow pharmacists to administer hormonal contraceptives and prescription smoking-cessation drugs, and independently initiate and administer routine vaccinations. The bill would also create a new certification “advanced practice pharmacist,” which would allow a practitioner who is collaborating with one or more doctors to “adjust or discontinue a drug therapy” as long as they promptly notify the patient’s doctor.

Here too, the medical association balks. Phinney said his organization is concerned by broadening pharmacists’ abilities to administer vaccines. Currently they are only allowed to administer flu vaccines, but the new bill would extend that ability to the full range of routine immunizations recommended for children and adults.

Phinney said that broadening immunization powers could open the opportunity for certain immunizations to interact with other medications or therapies that a patient is undergoing, like cancer medications. He said a family physician’s broader medical training and longer residency requirements are needed to prevent problems.

“Pharmacists, frankly, are not trained in the broad range of conditions that could be considered,” Phinney said.

But proponents of the change, like Kenneth Schell, pharmacist in chief at Rady Children’s Hospital, said there is plenty of precedent for pharmacists taking a more direct role in patient care.

“Pharmacists have been successfully acting as direct care providers for decades in federal and managed care systems (like the) Veterans Affairs, Indian Health, Department of Defense and Kaiser,” Schell said in an email.